Clin Orthop Relat Res (2011) 469:798804

DOI 10.1007/s11999-010-1339-z

SYMPOSIUM: NONACCIDENTAL TRAUMA IN CHILDREN

Femur Fractures in the Pediatric Population

Abuse or Accidental Trauma?
Keith Baldwin MD, MPH, MSPT, Nirav K. Pandya MD,
Hayley Wolfgruber BA, Denis S. Drummond MD,
Harish S. Hosalkar MD, MBMS (Ortho), FCPS (Ortho), DNB (Ortho)

Published online: 7 April 2010

The Author(s) 2010. This article is published with open access at Springerlink.com

Abstract
Background Child abuse represents a serious threat to the
health and well-being of the pediatric population. Orthopaedic specialists will often become involved when child
abuse is suspected as a result of the presence of bony
injury. Distinguishing abuse from accidental trauma can be
difficult and is often based on clinical suspicion.
Questions/purposes We sought to determine whether
accidental femur fractures in pediatric patients younger
than age 4 could be distinguished from child abuse using a
combination of presumed risk factors from the history,
physical examination findings, radiographic findings, and
age.
Methods We searched our institutions SCAN (Suspected
Child Abuse and Neglect) and trauma databases. We
identified 70 patients in whom the etiology of their femur
fracture was abuse and compared that group with 139
patients who had a femur fracture in whom accidental
trauma was the etiology.
Each author certifies that he or she has no commercial associations
(eg, consultancies, stock ownership, equity interest, patent/licensing
arrangements, etc) that might pose a conflict of interest in connection
with the submitted article.
Each author certifies that his or her institution approved the human
protocol for this investigation, that all investigations were conducted
in conformity with ethical principles of research, and that informed
consent for participation in the study was obtained.
K. Baldwin, N. K. Pandya, H. Wolfgruber,
D. S. Drummond, H. S. Hosalkar
Department of Orthopaedic Surgery, The Childrens Hospital
of Philadelphia, Philadelphia, PA, USA
H. S. Hosalkar (&)
Rady Childrens Hospital, UCSD, 3030 Childrens Way,
Suite 410, San Diego, CA 92123, USA
e-mail: HHOSALKAR@rchsd.org

123

Results A history suspicious for abuse, physical or

radiographic evidence of prior injury, and age younger than
18 months were risk factors for abuse. Patients with no risk
factors had a 4% chance, patients with one risk factor had a
29% chance, patients with two risk factors had an 87%
chance, and patients with all three risk factors had a 92%
chance of their femur fracture being a result of abuse.
Conclusions Clinicians can use this predictive model to
guide judgment and referral to social services when seeing
femur fractures in very young children in the emergency
room.
Level of Evidence Level III, diagnostic study. See
Guidelines for Authors for a complete description of levels
of evidence.

Introduction
Orthopaedic surgeons play a critical role in evaluating
potential cases of child abuse because fractures represent
the second most common presentation of abuse behind
only soft tissue injuries [23]. There are numerous studies
that have focused on the characteristics of fractures considered typical of abuse, including fractures of the femur
[1, 4, 5, 9, 14, 19, 28, 29], humerus [3, 12, 19, 31], tibia
[4, 12, 18], and ribs [6, 33]. Yet, orthopaedic surgeons are
less likely than general pediatric and emergency room
colleagues to identify abuse as the potential etiology of
these fractures, thus causing delay for appropriate multidisciplinary intervention [15, 26]. This is concerning
because of the million children annually in the United
States who are the victims of substantiated abuse, orthopaedic surgeons are often the first clinicians to evaluate
these patients, and if the cause of injury is not recognized,
these children will return to an abusive environment with a

Volume 469, Number 3, March 2011

50% risk for reinjury and a 10% risk of death [7, 13]. It is
therefore essential orthopaedic surgeons not only treat the
fractures these children present with, but also recognize the
associated etiologic characteristics of the injury that may
suggest child abuse.
When examining a fracture in the emergency room, the
following questions should arise: What patient characteristics may be indicative of abuse versus accidental trauma?
Is the history and mechanism of injury inconsistent with
the presenting injury? Does this fracture type, pattern, and
location represent potential abuse? Fractures of the femur
in young children provide an ideal model to develop a
systematic examination process to differentiate an abusive
from accidental etiology.
Fracture of the femur in children is the most common
musculoskeletal injury requiring hospitalization [5, 20].
Numerous studies describe fractures of the femur in young
children, and many of these have attempted to identify
fracture characteristics that may indicate abuse [2, 5, 8, 11,
20, 21, 24, 25, 28, 29]. The most common presentation
cited is the presence of a femur fracture in a patient
occurring either before walking age or before the second
birthday [5, 9, 13, 20, 28, 30]. In addition, several authors
have classified the radiographic appearance and location of
femur fractures as predictors of abuse [2, 15, 25, 28, 29] as
well as elements of the history (inconsistent history,
inappropriate delay, multiple presentations), physical
examination (examination inconsistent with history, head
injury or fracture in a child not of walking age), and
socioeconomic background [16, 22, 32]. A number of other
reports previously examined fracture patterns in children
younger than 48 months of age [6, 14, 16, 17, 26]. These
studies do not, however, allow a clinician to decide with
confidence whether a given femur fracture is likely caused
by abuse.
We therefore asked whether femur fractures caused by
abusive trauma could be distinguished from those caused
by accidental trauma using presumed risk factors in the
history, physical examination, and radiographic characteristics. We then built a predictive model based on those
factors.

Materials and Methods

Our institution is a large pediatric tertiary care center with
Level I trauma status with a large referral base. Institutional Review Board approval was obtained before data
collection. Since 1998, we have maintained an extensive
database (Suspected Child Abuse and Neglect [SCAN])
that examines all potential cases of suspected child abuse
and/or neglect. This database contains information identifying child abuse victims, demographic factors, and ICD-9

Femur Fractures in the Pediatric Population

799

and CPT codes relating to their concomitant diagnoses and

treatment. From that database, we identified all children
from birth to 48 months of age who had the diagnosis of
child abuse (ICD-9 code 995.5x) and the diagnosis of
femur fracture (ICD-9 code 820.x and 821.x). In addition,
we reviewed the general trauma database from our institution for all children presenting to the emergency room
and/or hospitalized with traumatic injuries for children of
the same age from 2000 to 2003 with the diagnosis of
femur fracture (ICD-9 code 820.x and 821.x). The general
trauma database contains data identifying trauma patients
that fit these characteristics, demographic information,
information regarding injury diagnoses, and subsequent
treatment. Information other than demographic information, injury code data and identifying information were
abstracted from the electronic medical record.
We calculated a power analysis for multiple logistic
regression as described by Hsieh et al. [10]. The power
analysis assumes a background abuse rate of 30% [9] in
patients with femur fractures in this age group with a difference in the rate in any given independent variable of
20%. The power analysis was conducted with a desired
two-sided alpha of 0.05 and a desired power of 0.80. The
analysis assumes a variance inflation rate (adjustment for
increased variability caused by multiple regressors) of 25%
for multiple regression. With these characteristics, our total
sample size would need to be 196 patients. Because our
analysis assumes a 30% event (abuse) [9] rate in femur
fractures, we would need 30% of our total cases to be from
abuse and 70% from accidental trauma (59 abuse cases and
137 accidental trauma cases).
Patients were identified in the study as a potential control (accidental) trauma case if they were found in the
general trauma database and did not have a diagnosis of
child abuse in their record and were not included in the
SCAN database. We excluded patients from the study if
they were younger than 48 months of age (except for one
patient, the SCAN database contained only patients
48 months of age and younger), if we could not adequately
confirm whether the case represented child abuse or accidental injury as a result of incomplete medical records
(three children), and if cases were erroneously placed in
either of the two databases (ie, did not represent either
child abuse or accidental trauma). This was the case in one
child in whom a diagnosis of femur fracture by ICD-9 code
was found but no record of this injury could be identified.
In addition, we excluded patients with known metabolic
bone disease or osteogenesis imperfecta. Seventy femur
fractures were from the child abuse cohort and 139 femur
fractures were from the accidental trauma cohort. These
209 total femur fractures represented the cases and controls
that would be analyzed in our study. The child abuse cohort
had a median age of 4.0 months. Of these 70 patients, 63

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Clinical Orthopaedics and Related Research1

Baldwin et al.

were younger than 18 months of age and seven were older

than 18 months of age. The accidental trauma cohort had a
mean age of 26.2 months. Of these 139 patients, 44 were
younger than 18 months of age and 95 were older than
18 months of age.
Patients were included in the SCAN database if hospital
personnel determined the patient was a victim of abuse or
neglect. The SCAN team consisted of an independent
group of nonorthopaedic physicians, nurses, and social
workers with advanced training in child abuse who
examined these children independently in the emergency
room and/or as inpatients and made the determination
whether the patients should be diagnosed with child abuse
and when child protective services should be activated.
Patients were included in the general trauma database if
they presented to the emergency room and/or were hospitalized with organ system trauma that necessitated an
evaluation from the hospitals trauma service, died in the
emergency department as a result of their traumatic injuries, or were initially seen in the emergency department
and transferred to another trauma center for management of
traumatic injuries. Both databases were collected and
maintained outside of the orthopaedic department at our
institution and were initiated many years before the retrospective review of the data that was performed by the
authors.
Data parameters collected from the patients medical
records included age at the time of injury, gender, insurance status, presence of current polytrauma (another
concurrent long bone, clavicle or axial skeletal fracture, or
other body system injury that would require hospitalization), and physical and/or radiographic evidence of prior
trauma. Furthermore, one of the authors (HW) who was
blinded to the SCAN status of patients examined the paper
and electronic medical records of the children and briefly
described the history of each patient. Subsequently, this
author categorized in a separate list the plausibility of each
patients history as either suspicious for abuse (unwitnessed accident, witnessed abuse, delayed presentation
greater than 48 hours, a mechanism that would not normally cause a fracture, or different stories provided by
different witnesses), or consistent with accidental trauma in

cases in which these criteria were not fulfilled, and then

transferred the list to the database. Two other authors (NP
and KB) reviewed the patient histories to determine if they
were consistent with accidental trauma or suspicious for
abuse. An intraclass correlation coefficient was generated
based on average measures (ICC 0.902, p value \ 0.001)
indicating agreement. Since many of the original radiographs for patients were no longer available, we examined
radiology reports to determine the location of the femur
fracture in all patients. The fractures were classified as
proximal, diaphyseal, or distal (each representing
roughly one-third of the length of the femur: subtrochanteric region, shaft region, and distal metaphyseal region).
Raw data from the databases were pooled, and means,
SDs, and/or percentages were calculated for age at time of
injury, gender, insurance status, presence of current polytrauma, physical and/or radiographic evidence of prior
trauma, history plausibility (consistent with accidental
trauma or suspicious for abuse), and radiographic femur
fracture location (proximal, diaphyseal, distal).
Because our age data were skewed we used the Mann
Whitney U test for independent samples to determine if
there was a difference in age at the time of injury between
the child abuse and accidental trauma patients. The chi
square test with Yates correction for independence or the
Fishers exact test in cases where the assumptions of a chi
square test were violated were used to determine differences in binary variables. We used binary logistic
regression to calculate adjusted odds ratios for a femur
fracture representing abuse as opposed to accidental trauma
using age at time of injury, gender, insurance status,
presence of current polytrauma, physical and/or radiographic evidence of prior trauma, history plausibility, and
femur fracture location as risk factors. Ninety-five percent
confidence intervals were calculated for proportions and
interquartile ranges for median values.
Child abuse victims were younger than accidental
trauma victims (median age 4.0 months compared with
26.2 months) and were more often female (49% versus
32%) (Table 1). There was no difference (p = 0.77)
between the abuse and accidental trauma groups in terms of
insurance status. Patients with femur fractures who were

Table 1. Demographic information for child abuse and accidental trauma patients for age, gender, and insurance status
Variable

All abuse (95% CI)

All accidental

Odds ratio (95% CI)

Number of patients

70

139

N/A

N/A

Age younger than 18 months

90.0% (83.0%, 97.0%)

31.7% (23.9%, 39.4%)

19.4 (8.3, 45.0)

\ 0.001*

Age (months)

4.0 (2.0, 8.3**)

26.2 (11.9, 34.8**)

N/A

\ 0.001

Gender (percent female)

Percentage without insurance

48.6 % (36.9%, 60.2%)

7.1% (1.1%, 13.2%)

32.4% (24.6%, 40.2%)

9.4% (4.5%, 14.2%)

2.0 (1.1, 3.6)

0.7 (0.3, 2.1)

0.033*
0.795

* Chi square test with Yates correction; Mann Whitney U test; Fishers exact test; **Interquartile range N/A = not applicable.

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p value

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Femur Fractures in the Pediatric Population

801

Table 2. Comparison of current polytrauma, prior trauma, and history plausibility in child abuse and accidental trauma patients with femur
fractures
Variable

Number
of abuses

Percent abuse
(95% CI)

Number accidental
trauma

Percent accident
(95% CI)

Odds ratio
(95% CI)

p value
\ 0.001*

Current polytrauma

37/70

52.8% (41.2%, 52.9%)

11/139

7.9% (3.4%, 12.4%)

13.0 (6.1, 28.1)

Physical and/or radiologic

evidence of prior trauma

44/70

62.3% (51.5%, 74.2%)

6/139

4.3% (0.9%, 7.7%)

37.5 (14.8, 94.7) \ 0.001*

History suspicious for abuse

23/70

32.9% (21.9%, 43.9%)

6/139

4.3% (0.9%, 7.7%)

10.8 (4.3, 27.5)

\ 0.001*

Raw number in parentheses; p values generated by Yates chi square test for independence; *statistically significant.

Table 3. Comparison of femur fracture location in child abuse and accidental trauma patients
Variable

Number
of abuses

Percent abuse
(95% CI)

Accidental
trauma

Percent accident
(95% CI)

Odds ratio
(95% CI)

p value

Proximal femur

14/70

20.0% (10.6%, 29.4%)

19/139

13.7% (8.0%, 19.4%)

1.5 (0.7, 3.3)

0.33

Femoral diaphyseal

32/70

45.7% (34.0%, 53.4%)

92/139

66.1% (58.3%, 74.1%)

0.4 (0.2, 0.8)

0.007*

Distal femur

26/70

37.1% (25.8%, 48.5%)

28/139

20.1% (13.5%, 26.8%)

2.3 (1.2, 4.4)

0.01*

Raw number in parentheses; p values generated by Yates; chi square test for independence; odds ratios compare patients who are positive for
each fracture type as the outcome and abuse as the risk factor; *statistically significant.

victims of abuse had a greater frequency of current polytrauma (53% versus 8%), physical and/or radiographic
evidence of prior trauma (62% versus 4%), and histories
that were deemed suspicious for abuse (33% versus 4%)
(Table 2). Patients with accidental trauma more often had
diaphyseal femur fractures (46% versus 66%), abuse victims more often had distal femur fractures (37% versus
20%), and there was no difference in proximal femur
fractures between groups (Table 3). The odds of a femur
fracture being the result of abuse rather than accidental
trauma was greater for children younger than 18 months
(19.4 times) and patients of female gender (2.0 times)
(Table 1). Furthermore, abuse was associated more frequently with current polytrauma (13.0 times), physical and/
or radiographic evidence of prior trauma (37.5 times), and
patients with a suspicious history (10.8 times) (Table 2).
Finally, we used a multiple logistic regression model to
calculate a prediction rule for the chance of abuse given the
aforementioned risk factors. All of the variables that were
significant in any portion of the study were used. In addition, variables previously judged important were included
in the initial multiple logistic regression model. The variables were entered using the backward likelihood ratio
method for selection of variables. All variables were
entered and criteria of 0.10 by the 2 log likelihood
method was used for removal of variables. In the backward
regression analysis, only age younger than 18 months,
physical and/or radiographic evidence of prior injury, and
history of plausibility were predictive of an abusive etiology for child abuse. In this model, patients with a femur

Table 4. Multiple logistic regression model with number of risk

factors (risk factors: age younger than 18 months, physical and/or
radiologic evidence of prior trauma, and suspicious history)
Variable

Beta
statistic

Odds ratio
(95% confidence interval)

p value

One risk factor

2.0

7.2 (2.223.5)

\ 0.001*

Two risk factors

5.0

155.5 (41.6581.0)

\ 0.001*

Three risk factors

5.6

273.0 (28.12649.0)

\ 0.001*

* Statistically significant.

fracture whose age was younger than 18 months had a 10

times greater chance of being the victim of abuse than
older children. Patients who had the presence of prior
trauma on physical and/or radiographic examination had a
16.8 times greater chance of having been a victim of abuse
than patients who had no such findings. Finally, patients
with a suspicious history had a 7.4 times greater chance of
having been abused than patients with a plausible history
after considering the other factors in the model.
Given these findings, a new simpler logistic regression
model was built based on the outcome of the first model
(Table 4). This model was built with the three significant
variables in the first model. The variables entered were
whether the patient had one, two, or three risk factors (risk
factors from the first model: age younger than 18 months,
physical and/or radiographic evidence of old trauma, and
history suspicious for abuse). This final model did not
differ (p = 0.69) from the old model using the 2 log
likelihood method of comparison.

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Clinical Orthopaedics and Related Research1

Baldwin et al.

PATIENT PRESENTS TO CLINIC OR EMERGENCY DEPARTMENT

WITH FEMUR FRACTURE

CLINICIAN ASSESSES NUMBER OF RISK FACTORS FROM

FOLLOWING LIST:

1) AGE < 18 MONTHS

2) PHYSICAL AND/OR RADIOGRAPHIC EVIDENCE OF PRIOR
TRAUMA
3) SUSPICIOUS HISTORY

0 RISK
FACTORS

4.2%

1 RISK
FACTOR

2 RISK
FACTORS

24.1 %
87.2%
RISK OF ABUSIVE
FEMUR FRACTURE

3 RISK
FACTORS

92.3%

Fig. 1 The figure shows our algorithm for determining whether a

femur fracture stems from abuse or accidental trauma based on our
regression model.

Results
A simple model using number of risk factors (age younger
than 18 months, physical or radiographic evidence of prior
injury, and suspicious history) predicted abuse in this age
group. Odds ratios were calculated based on the logistic
regression model versus a patient with no risk factors
(Table 4).
The logistic regression equation was then solved for each
number of risk factors to develop a prediction tool. In our
population, patients with no risk factors had a 4% chance of
having abuse as the etiology for their femur fracture, patients
with one risk factor had a 24% chance abuse was the etiology
of their femur fracture, patients with two risk factors had an
87% chance abuse was the etiology of their femur fracture,
and patients with three risk factors had a 92% chance abuse
was the etiology of their femur fracture (Fig. 1).

Discussion
Pediatric femur fractures are the most common musculoskeletal injury requiring hospitalization [5, 20], and their
presence in children raises suspicion for abuse [2, 5, 8, 11,
20, 21, 24, 28, 29]. In fact, it has been proposed that onethird of femur fractures in children younger than age
4 years and 80% of femur fractures in children who are not
yet walking have an abusive etiology [9]. Multiple studies
have attempted to classify the demographic and fracture
characteristics of children whose fracture may have an
abusive etiology, including age (particularly before walking age or the second birthday) [5, 9, 13, 20, 28, 30],

123

radiographic appearance and location of the fracture [2, 15,

28, 29] as well as elements of the history, physical examination, and socioeconomic background [16, 22, 32].
Because femur fractures are a common entity that the
orthopaedic clinician will evaluate in the emergency room
and are linked to child abuse [2, 5, 8, 11, 20, 21, 24, 28,
29], it is essential for the orthopaedic clinician to be able to
differentiate an abusive from an accidental etiology so that
proper multidisciplinary action can be initiated to protect
children from an abusive environment. In light of this fact,
and the fact that one recent investigation suggests fracture
pattern may not be as useful in determining fracture etiology [29], there exists no prediction algorithm with which
to help a clinician assign etiology to an injury. We presumed femur fractures resulting from accidental trauma
could be differentiated from femur fractures resulting from
abuse using history, physical examination, demographic
factors, and radiographic findings, and a prediction model
based on these parameters can be generated to allow clinicians to more accurately identify victims of abuse and
distinguish abuse from accidental trauma.
There are several limitations in our study. First, our
prediction rule was generated from an urban Level I pediatric trauma center. It is unclear if the prediction rule would
be different for pediatric patients presenting to lower-level
pediatric trauma centers in nonurban environments and/or
in different countries. However, our tertiary referral status
allows us to say we attract patients from a broad catchment
area, hence enhancing our external validity. Second, it can
be argued our assessment of history status (consistent versus
suspicious) is subjective. Specifically, arguments for mitigating individual circumstances such as unwitnessed injury
could be due to a momentary lapse in supervision; delay in
seeking care could be due to lack of health insurance or a
child who is not expressing substantial discomfort. However, our criteria for suspicion are consistent with previous
reports [6, 27, 30]. In addition, although our blinded rater
was instructed to look at only the history and physical
records to determine the patient history without viewing
other aspects of the medical record, she was not strictly
blind to the SCAN status of the patient because she had
access to the medical record. The use of corroborating
investigators with a high intraclass correlation coefficient
somewhat mitigates this risk. Third, as a result of the fact
that child abuse is largely a social diagnosis, there exists no
test that can confirm the presence or absence of child abuse
with a high level of specificity or sensitivity. Yet, we
believe evaluation by independent specialists constitutes the
best method available in the current literature. Inclusion in
the SCAN database is determined by an independent group
of social workers, nurses, and physicians who all have
advanced training in child abuse (and are independent from
the authors) at the time the child presents to the emergency

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Femur Fractures in the Pediatric Population

room, and is also used for a clinical purpose (ie, activating

child protective interventions). As with any study of child
abuse, the study risks circuitous logic, that is to say, child
abuse is often diagnosed by suspicious history, physical
examination findings, and other social factors. However,
this could be said about any condition that is a clinical
diagnosis; as such, we believe guidelines for diagnosis of
this condition are helpful.
The use of age, history, physical findings, and radiographic findings to assess for child abuse is not new
(Table 5). Although these multiple characteristics are
essential in providing a general picture of a pediatric
patient presenting with child abuse, the question arises as to
how these characteristics can be applied in a quantifiable,
objective manner to help to reliably predict etiology for a
clinician. Whereas other studies have limited their analysis

803

to descriptions of abusive and accidental femur fracture, the

prediction model developed from our study allows for
research to be translated into clinical action. Of the multiple
demographic characteristics in our study, the multiple
regression model identified the following three predictors
after accounting for other confounders when differentiating
abusive from accidental femur fractures in this age group:
(1) age younger than 18 months; (2) physical and/or
radiographic evidence of prior trauma; and (3) history
suspicious for abuse. Clinicians can use this rule in the
following fashion: patients with no risk factors have a 4%
chance of having a femur fracture stemming from child
abuse; patients with one risk factor have a 24% chance;
those with two risk factors have an 87% chance; and those
with three risk factors have a 92% chance of having a femur
fracture stemming from abuse.

Table 5. Risk factors found to be important or used to help diagnose child abuse
First
author

Age as a risk factor

for abuse

Historical features

Physical examination Radiographic

features
or other features

Anatomic location

Coffey
67% (extremity
et al. [4]
injuries were in
patients younger
than 18 months)

N/A

N/A

N/A

Not available within specific fracture

groups

Rex and
92% (younger than
Kay [28]
1 year)

N/A

N/A

N/A

No difference in site of fracture

(proximal/middle/distal)

Schwend
et al.
[30]

42% of children
younger than
walking age with
femur fractures

Suspicious, inconsistent Bruises or

history or delayed
polytrauma
presentation used to
characterize

Multiple fractures

All were shaft fractures

Leventhal
et al.
[17]

60% (younger than

1 year femur
fractures)

Suspicious history,
None listed for
change in behavior
femurs
or Medicaid payor

None listed for

femurs

None listed for femur fractures

Suspicious, inconsistent Bruises or multiple

history or delayed
injuries
presentation

Multiple fractures

No specific pattern, study speaks in

terms of fracture plausibility

N/A

N/A

Pierce et al. 50% younger than

[27]
1 year with
probable abuse.

Loder and 15% (younger than

N/A
Bookout
2 years)*
[18]
Scherl et al. 13% of total cohort, Suspicious history
[29]
but average age of
confirmed abuse
0.83 years

N/A

Bilateral injuries
Associated injuries
worked up more
often, but only 1/7
were positive

No particular distribution

Fong et al.
[6]

52% of abuse
patients younger
than 3 years old
(all fractures)

Suspicious, inconsistent None specified

history or delayed
presentation

Fractures in various No anatomic distribution noted

stages of healing
within femur fractures

Worlock
et al.
[33]

80% abusive
fractures in those
younger than
18 months

No historical
Bruising of the head Rib fractures in the 50% metaphyseal chip in the femur
information available
and neck
absence of chest
in abuse patients; in other long
trauma, multiple
bones, spiral or oblique fractures
fractures
more common

Baldwin
et al.
[current
study]

90% abused children Inconsistent or

Consistent with other Consistent with
younger than
suspicious history, or
injuries or prior
prior injury
18 months
delayed presentation
injury

Distal more often abuse shaft more

often accident

* Based on the 2000 kids inpatient database; N/A = no available data in the study.

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Baldwin et al.

It is essential for clinicians to be able to differentiate

the etiology of pediatric femur fractures as stemming
from abuse or accidental trauma. Not only are femur
fractures a common injury seen by orthopaedic clinicians,
but identification of the etiology of the injury is vital to
ensure proper multidisciplinary intervention can be initiated for the safety of the child. Prediction based on the
multiple logistic regression model that was developed in
our study can help determine the etiology of pediatric
patients presenting with a fractured femur. Although
further studies will be necessary to validate the rule
prospectively, we believe the rule is a good common
sense approach to a young patient with a femur fracture.
We believe this method will help all clinicians determine
whether child abuse occurred and thus enhance their
approach to management.
Acknowledgments We thank Dr Cindy Christian, and the Department of Pediatrics at the Childrens Hospital of Philadelphia. In
addition, we acknowledge the SCAN team and the Department of
Emergency Medicine and Trauma at the Childrens Hospital of
Philadelphia.
Open Access This article is distributed under the terms of the
Creative Commons Attribution Noncommercial License which permits any noncommercial use, distribution, and reproduction in any
medium, provided the original author(s) and source are credited.

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before walking age. J Pediatr Orthop. 2007;27:751753.
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